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Kanmaniraja et al. Hepatoma Res 2020;6:51 I http://dx.doi.org/10.20517/2394-5079.2020.46 Page 9 of 11
[7,8]
antecedent surveillance ultrasound . Additionally, v2018 updated the definition for threshold growth
to be congruent with that of the Organ Procurement and Transplantation Network: threshold growth
[8]
is defined as ≥ 50% increase in size of a mass in ≤ 6 months . Any other size increase, including new
observations and observations with ≥ 100% increase in size on studies > 6 months apart, are characterized
[8]
subthreshold growth .

LI-RADS: ADVANTAGES FOR CLINICIANS
As the diagnosis of HCC is often made based on imaging findings alone in patients at risk without the need
for a biopsy confirmation, it is imperative to maintain a high level of accuracy among radiologists in both
the interpretation and the reporting of liver observations [24-26] . LI-RADS uses a strict diagnostic criterion
and an algorithmic approach to determine the likelihood of focal liver observations being HCC, while
maintaining substantial inter-reader reliability and a high specificity for HCC [17,27,28] . In fact, LI-RADS inter-
reader agreement on MRI compares favorably to other commonly used RAD systems, such as breast and
[29]
prostate .
The use of non-standardized lexicon in liver imaging reports may result in confusion, especially when
[30]
communicating results to the referring clinicians . The same phrase may be used differently by different
[31]
[31]
radiologists and may be interpreted differently by the referring clinicians . Corwin et al. reported that
the use of radiology phrases such as “consistent with HCC” and “suspicious for HCC” were associated with
a high variability in the LI-RADS categories. Conversely, use of LI-RADS terminology and reporting results
[32]
in a more comprehensive, clearer, and ultimately more actionable report .

DISCUSSION
While LI-RADS offers numerous advantages for radiologists, clinicians, and patients, the system is not
perfect. Unlike many other imaging-based systems for HCC diagnosis which have binary approach for
diagnosis (i.e., HCC vs. all other lesions), LI-RADS utilizes ordinal categories which reflect increasing
probability of HCC. Furthermore, LI-RADS is unique in that it recognizes the increased risk of non-HCC
malignancies in patients with cirrhosis and provides diagnostic criteria for LR-M category. This level of
detail requires greater complexity of the diagnostic criteria, and as a result LI-RADS may be intimidating
for novice users or may be perceived as too cumbersome for clinical practice. However, a recent survey
of radiologists and clinicians found that nearly 90% preferred the use of LI-RADS compared to other
standardized reporting systems .
[33]
LI-RADS has undergone several major updates since its original release in 2011. As scientific evidence
[7]
accumulates, and user feedback is accrued, the criteria are refined and updated . The goal of each release is
[7]
to improve accuracy and ease of use . The need for the system to be in congruence with the latest scientific
[7]
knowledge is balanced against the need for a stable system . As a result, major updates to the system are
planned for every 3-5 years.

CONCLUSION
This manuscript reviews CT/MRI LI-RADS. CT/MRI LI-RADS is a comprehensive and dynamic system
with standardized terminology and an algorithmic diagnostic approach for the diagnosis and subsequent
management of HCC, enabling clear communication between radiologist and clinicians. The most recent
version has revised its criteria for LR-5 and simplified its definition for threshold growth, and it is now
incorporated into the AASLD HCC practice guidelines.

DECLARATIONS
Authors’ contributions
Made substantial contributions to drafting, editing and finalizing of the draft: Kanmaniraja D, Chernyak V